MEDICARE: KIMBERLY CLARK PHILLIPS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN365963	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RN365963	OTHER	OH	OHIO BOARD OF NURSING

General Provider Information

NPI Number	:	1699004135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY CLARK PHILLIPS RN

Provider Business Mailing Address
First Line	:	9464 UNIONVILLE RD
Second Line	:
City	:	PLAIN CITY
State	:	OH
Zip	:	43064-9734
Country	:	US
Telephone Number	:	614-332-0765
Fax Number	:	614-873-2811

Provider Business Practice Location Address
First Line	:	9464 UNIONVILLE RD
Second Line	:
City	:	PLAIN CITY
State	:	OH
Zip	:	43064-9734
Country	:	US
Telephone Number	:	614-332-0765
Fax Number	:	614-873-2811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2009
Last Update Date	:	11/16/2010

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